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Quote of the Week:

"Obstetrics should be both art and science. The science lies in what we know to be true, the art lies in how that information is used for greatest benefit to mothers and babies."

- Don Creevy, OB

The Art of Midwifery

For heartburn during pregnancy: Chew a few pieces of diced papaya before meals.
Papaya tablets are also safe--just follow the directions.

The best way to handle heartburn, however, is to prevent it. No super-spicy
meals, eat small meals more frequently, bananas soothe the stomach, do not lie
down after a meal but try walking or moving your body a bit. The sphincter muscle
at the top of your stomach relaxes right along with all the rest of your body
to soften up for birthing, and food/stomach acid can get pushed up. This is where
the burning part comes in.

Another handy little remedy is slippery elm throat lozenges available from health
food stores. Slippery elm bark is safe for pregnancy and it soothes the stomach,
but take it only if/when the above suggestions do not work.

News Flashes

Reduced growth in utero is associated with noninsulin dependent diabetes and
impaired glucose tolerance in adult life. Researchers studied people born before,
during, and after a famine that occurred in the Netherlands from November 1944
to May 1945 and found that people exposed to famine in utero during the second
and third trimesters of pregnancy show impaired glucose tolerance and insulin
resistance, which predispose to both diabetes and heart disease. The most significantly
affected were exposed during the third trimester. Affected people were also more
likely to be obese as adults. Official rations during the famine varied from 400
to 800 calories per day. The study findings of glucose intolerance in adults exposed
to maternal malnutrition in fetal life adds credence to the hypotheses of fetal
origins of adult disease. Permanent changes in pancreatic function and other body
systems occurred in these subjects.
- The Lancet, Vol. 351, no 9097, January 17, 1998.

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Due Date

The concept of [a due date] is based on a gestational length established by
fiat in the early 1800s. Franz Carl Naegele officially declared that pregnancy
lasted 10 lunar months (10 x 28 days), counting from the first day of the last
menstrual period). However, when Mittendorf et al. measured the median duration
of pregnancy, they found that healthy, white, private-care, primiparous women
with well-established due dates averaged 288 days and multiparas averaged 283
days, values significantly different from both Naegele's rule and each other.
Others have found similar results. Mittendorf et al. also cited other studies
showing racial differences in gestational length. For example, one showed that
black women averaged 8.5 days fewer than white women of similar socioeconomic
status.

Moreover, ultrasound-determined due dates are not accurate. One study used the
date established by ultrasound at 16 to 18 weeks to test the validity of dating
by the last normal menstrual period (LNMP). It found that as gestational age went
past term, positive predictive values for the LNMP declined from 95% to 12%. The
authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound
date is the problem. Even first trimester measurements have an error bar of +/-
5 days in the second trimester and +/- 22 days in the third.

Few practitioners appreciate the limitations of ultrasound or clinical data.
Otto and Platt say the due date should not be changed unless the discrepancy is
more than two weeks, yet they see doctors changing a due date by a few days, no
trivial alteration if a woman will be induced when she exceeds a certain date.

Some risk does accrue in healthy postdate pregnancies (notably meconium passage
and big babies) but it does not follow that we should induce all women. Studies
have found that as gestational age goes from 37 to 44 weeks, perinatal mortality
and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate
pregnancies on grounds of increased complications, should we not equally logically
try to delay labor onset in the early-term group?

A prospective study was conducted at a West German US Army Hospital to compare
the accuracy of fetal weight estimation by a physician's clinical estimate as
compared to ultrasound. One hundred women had Leopold's and vaginal examinations,
an estimate was made. Then the same examiner performed an ultrasonic estimation
of weight. The exam was done within 48 hours of delivery. The mean error for the
clinical estimate was 7.9%. The error by ultrasound was 8.2%. There was no significant
statistical difference between the two types of estimates, including for the extremes
of birth weight.
- Journal of Reproductive Medicine, Vol. 33 No. 4, April 1988

====

Wood's method: Carol Wood, Yale nurse-midwifery professor, came up with a method
to calculate the due date that takes into account individual variations in the
menstrual cycle as well as the effect of a woman's having had previous pregnancies.

1. Add 1 year to the first day of the last menstrual period, then
For first-time mothers, subtract 2 months and 2 weeks
For multiparas, subtract 2 months and 2.5 weeks (18 days)
2. Add or subtract the number of days her cycle varies from 28 days

Check It Out!

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Midwifery Today's Online Forum

I've been told that too much vitamin E in late pregnancy can cause placenta
Accreta and thin blood. Can that be true? I've been taking it to get those extra
EFAs and I was hoping to continue taking it after the birth to speed healing.

Go to our forums to share your thoughts and experience.

Question of the Week

Q: When you attend homebirths, what do you keep in
your kit ahead of time for those unexpected, middle-of-the-night calls? And what
is the most effective way to organize and carry your materials and supplies?

LUCK OF THE DRAW: We'll draw a name from among the respondents to this question--the
winner will get a free copy of our latest Tricks of the Trade
book!

To qualify, **please include your email address in the body of your message**.

Question of the Week Responses

Q: Would readers please share their experience with
and information about endometriosis and pregnancy/labour? Our pregnant client
has quite severe endometriosis with nonpregnant symptoms of frequent nausea, very
painful cramping premenstrually and during menstruation, heavy bleeding, and bleeding
from the rectum.

- Anon.

====

A: My first experience with a client with such severe endometriosis before
and during pregnancy was more than 20 years ago. Beloved homebirth physician (wholistic
MD and naturopath), Dr. Paul DuGre responded with nutritional advice: immediate
daily supplementation of 1200 mcg. folic acid along with the rest of the B-complex
vitamins in the more digestible and assimilable brown rice based form. He also
suggested "Floradix Liquid Iron and Herbs" at one ounce per day for
the first week, then 1/2 ounce daily. He recommended replacing starchy, sugary,
processed foods with whole grains and natural foods high in vitamins and minerals,
and vegetable proteins because they digest more easily and do not overstress the
colon and rectum, and would help regenerate strong cells in the woman's body.
The advice included eating lots of gentle fruits such as avocadoes and those rich
in enzymes, as are papayas, bananas. Paul encouraged kegel exercises and general
low-stress exercise such as swimming.

Paul also warned about what to avoid such as table salt (cheap sodium chloride),
which should be replaced with mineral-rich salt such as sea salt and a sufficient
amount of potassium-rich foods. He described the toxic side effects of additives
like aspartame (Nutrasweet) and of sodium fluoride that has been infiltrated into
city water and toothpaste and which proved to be harmful to women's systems and
unborn babies (mentioning that the original idea of calcium fluoride might have
been beneficial in some ways, but that the less-expensive sodium fluoride proved
to be extremely harmful, especially to women's systems and unborn babies.)

- Julia Swart

====

A: Endometriosis is a condition in which the cells that create the lining
of your uterus also grow inside your pelvis. Each month these cells thicken as
if they were in the uterus, but they cover the outside of the ovaries, fallopian
tubes, uterus, and the ligaments in the pelvis. Then like the lining of the uterus,
they bleed each month--except there is nowhere for the blood to go and it sits
in the pelvis, clots, and causes adhesions and pain. Some of these adhesions are
called chocolate cysts and they grow on the ovaries.

There are many signs of symptoms and endometriosis and not everyone gets all
of them, which makes it hard to diagnose. Signs & symptoms: heavy painful
periods, pain during ovulation, pain during intercourse, constipation or diarrhea
around period time, pain around the rectum, PMS, spotting of brown discharge two
to three days before a period actually starts, and many more. Doctors used to
think it was a condition that only older women got but now they know that one
can have it from teen-age. When one becomes pregnant all these symptoms cease
or decrease considerably until the baby is born. Usually the symptoms remain at
bay as long as a woman breastfeeds but often return to some degree once menses
commence again.

The Australian book "Explaining Endometriosis" by Ann Henderson
can probably be found at your library or bookseller.

- Diana Stubbs, RM, IBCLE, BA Nurs
Geelong, Australia

====

A: Seek a naturopathic physician in your area to get the best treatment
advice.

- Leslie Peterson, ND
SLC, UT

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~*~*~*~*

Re: Midwife Melissa Jonas's statements about respecting all woman's choices
[Issue 3:46]: I agree to a point, but the question is whether women who choose
high-tech birth are doing so because they are truly informed and educated about
their health and birth choices or because that is what they are told they need
to do? Are they choosing high tech out of fear and ignorance? Most women today
have no idea that they have choices, or that there are risks to high-tech/high-intervention
births. We live in a society that assumes that more technology is better and that
the medical care provider is the best person to make decisions regarding one's
health. This is an extremely complicated issue. Korte and Scaer said in A Good
Birth, A Safe Birth, "If you don't know your options, you don't have
any."

On the other hand I remember a story that Penny Simkin told of an abused woman
who chose a drugged birth because she wanted one day in her life without pain.
Who could blame her?

We need to talk with the women we work with and find out why they are choosing
the things they are and make sure they are truly informed before making those
decisions. You never know which category she may fall into.

- Amy V. Haas, BCCE
Fairport, NY

====

I felt compelled to respond, in way of thanks, to a sensitive and insightful
letter written by M. Jonas, LM. You have written as a homebirth midwife who has
extended herself to the nonhomebirth women (for whatever their reasons), and by
association I feel to those of us who care for women giving birth in hospitals.
Many in the homebirth community do quickly write off, so to speak, those women
and those midwives caring for them as somehow doing it the wrong way, which may
simply be doing it a different way. You mentioned "the lack of compassion
for women making choices other than those we recommend," which is caused
by judgments and affects interactions with them as well as conveys a lack of respect.

As a CNM practicing in an urban hospital, with private patients, I too must
keep constant vigil against not wanting women to make choices I would not make,
when I have offered a noninterventionist approach. We have jacuzzis, showers,
birth balls, etc., and yet I too have to remember that I must support women in
an informed decision, this is their birth, these are their choices, and I have
chosen to be "with woman" whether or not she is choosing to do what
I think best or useful. For all midwives, in all locations, I appeal for unity
and respect that we might best serve all the women in their diverse natures that
live among us.

- Trish McPeak-LaRocca, CNM

====

Giving birth is about having a baby. Particularly in America the choices women
often feel they have the right to make do not include the needs of her baby. I'm
not talking about, e.g. someone who has unresolved sexual abuse issues and is
terrified of labor and delivery and so opts for a cesarean, but about the average
woman with average prenatal care and the "average" caregiver. The choices
she is generally informed about typically leave out or minimize vital information
about possible effects of her choices on her baby and possibly also on the relationship
between mother and baby as a result. When a mother contemplating an epidural is
asked "Why be a martyr?" she is not told that babies exposed to more
than an hour's worth of obstetrical medications are, at worst, more predisposed
to become substance abusers than those who are not, and at best, may experience
feeling disconnected from their bodies, fuzzy thinking when under stress, feeling
inadequate and incapable of completing things they start, and a whole list of
other possible consequences, she is not truly making an informed choice. Nor is
she being informed that motherhood begins before conception with the intention,
or not, to conceive a child, nurture it in the womb for nine months, and encounter
the profound spiritual, physical, family, rite of passage that birth was designed
to be, so that when she has accomplished it she will, as the research has shown
us, feel more confident in herself as a mother, more delighted in her baby, more
likely to breastfeed and for longer, etc. than a woman who experienced less pain
with her epidural, but missed the endorphins, the sense of accomplishment and
wonder, and the ability to bond with an alert baby rather than a sleepy one with
a poor suck who gets cranky about a week later when the drugs finally clear his/her
system.

The very reason for giving birth, the baby, all too often in this culture gets
left out of the equation except as a cute "product" of all this planning
and devising and orchestrating and intervening. I'm reminded of Leboyer's photograph
in his book "Birth without Violence" (published in the 70s!)
showing everyone smiling at the success of the birth while the baby is held upside
down by his feet, his hands on his ears and an expression of unadulterated anguish
on his face. Have we really come very far since then as far as the baby is concerned?

Meanwhile, studies of prenatal communication between babies and parents point
the way to a very different form of birth plan: one in which mother and baby are
in communication with each other, in which mother trusts her intuitions about
her baby and her body, in which baby trusts mother to move as she needs to in
order to assist its passage through the birth canal, in which the motherbaby dyad
work fluidly together to accomplish the birth as a profound celebration, and father
stands guard as a protector of the birthing process in his family as well as loving
support for his partner and child. This is a birth in which baby is informed of
any procedure to be initiated that will impact him/her before it is begun: a birth
in which the personhood of the baby is acknowledged, respected, and included in
planning and decision-making. This type of birth has always been possible, but
the machines that go "ping" are so enticing.

- Claire Winstone, M.A.,educator: pre- & perinatal psychology, doula

====

Regarding labor and cramping, make sure enough calcium/magnesium is in the diet.
I've "cured" many of my menstrual cramps with cal/mag. I was also given
a recipe for a "labor ade" from my midwife to drink during labor, which
included--wouldn't you know it--crushed cal/mag tablets.

- Anon.

====

I had a baby three months ago. I was unable to see my very busy midwife again
until nine weeks postpartum. Apparently one of my stitches popped open during
initial healing and some underlying tissue snuck out. I was told to wait two more
weeks to see if it would heal, and if it didn't, to come back. At my next visit
an OB/GYN checked me out. I have to go to the hospital for a fistulagram to see
if I have any fissures. Has anyone ever dealt with this situation? How would a
homebirth midwife assess internal tearing? Is there any way to put that tissue
back in place without being sliced open? (I opted to tear because of the research
I had done on episiotomy. Is there anything I can do herbally or homeopathically
to heal quickly, keep from getting infection, and avoid that whole "pain
during sex" thing for the rest of my life?

- Abbie

====

Re: separation of abdominal muscles postbirth [Issue 3:46]:

It's called a divided rectus sheath; many women experience this. Simple exercises
should close the gap. You may wish to discuss this with a physiotherapist. Exercises
should not be painful and are usually started in the first week postpartum, gently
at first, then increasing. My own gap closed after a month or two. It's better
to have strong muscles than weak divided ones!

- Margaret Watson, UK midwife

====

When you do the sit-ups, focus on pulling the muscles together by hugging your
arms across your body in an "X" pattern. Only lift slightly and pull
at the same time. Also make sure you are using your abs and not your neck, shoulders,
or back to pull up. Make sure your pelvis is tilted toward your sternum. (From
Denise Austin's Pregnancy Plus Workout.)

- Jennifer Crowley

====

I had this same muscle separation following my third pregnancy. My midwife taught
me to cross my arms over my belly, and with my hands grasping the outsides of the muscles and pulling them INWARD across the abdomen, doing my crunches. Just
doing plain sit-ups won't help bring the muscles together again. You need to "train"
them together by pulling them together with your hands (during the sit-up). Shape's
"Fit Pregnancy" magazine publishes photos of this procedure every so
often. They may have it at their online Web site.

- Cherwyn

====

In my previous practice I referred women with this problem to a physiotherapist.
The condition is labeled "diastasis of the rectus abdominii." In other
words, the muscles have separated! The immediate care for these women was to give
them a very supportive tubular "corset" of "tubigrip" that
supported the abdomen from just under the breasts to just below the pubic bone.
The exercises recommended were very shallow curl-ups with knees bent and arms
sliding up the legs to the knees only. She would have them start with two pillows
under their heads for several days, then gradually remove the pillows. Great emphasis
was placed on being very careful of getting out of bed--i.e., turn on side, then
get up, and also not lifting anything heavier than the baby. The rectus muscles
act as a corset and support your spine, so you have to be very careful to lift
and bend properly. I am guessing, but you may find in future pregnancies that
you "pop" out sooner and may need some support for your growing uterus.

- Mary Jo

====

I've read countless times about how you shouldn't rush the delivery of the placenta.
I had my first baby 19 months ago, and my midwife had me pushing to deliver my
placenta right after birth. She also tugged very gently to help it along. I believe
it was because I had a tear from the birth that she wanted to stitch up before
I lost too much blood. I had no ill effects from a "rushed" placental
delivery that I know of. Is this an exception to the rule? If there is a tear
to be closed, how does this affect delivery of the placenta?

- Jennifer

====

I am 37 and pregnant with my third child. I had a placenta abruption and emergency
c-section at 34 weeks with my first child, and the same with my second child at
38 weeks. Am I risking too much to want to try to have a vaginal birth if I can
make it that far without the placenta abrupting? Have any midwives ever had clients
in this situation? I'm 45 minutes away from a competent hospital. I don't smoke,
didn't have gestational diabetes, high blood pressure or any problems before it
happened.

- LaDonna in N.C.

====

EDITOR'S NOTE: Only letters sent to the E-News official email address,
mtensubmit@midwiferytoday.com,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
not be considered.

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